CMN_Neurolysis_Final
|Certificate of Medical Necessity: |[pic] |
|Neurolysis | |
| |
|Fax or mail this | |For Pre-Service: Statewide Fax (877) 219-9448 |
|completed form | |For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614 |
| | |For Post-Service Claims: |
| | |Florida Blue |
| | |P.O. Box 1798 |
| | |Jacksonville, FL 32231-0014 |
|Section A |
|Physician Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Requesting Provider | | | |
| |Contact Name: |Phone: |
|Facility Information/ |Name: |BCBSF No: |National Provider Identifier (NPI): |
|Location where services will be| | | |
|rendered | | | |
| |Contact Name: |Phone: |
|Member Information |Last Name: |First Name: |
| |Member/Contract Number (alpha and numeric): |Date of Birth: |
|Procedure Information |Procedure Code(s): |Procedure Description: |
| |Diagnosis code(s): |Diagnosis Description: |
| |Date of Service/Tentative Date: |
|Section B |
|Medical Necessity: For detailed information on the criteria that meet the definition of medical necessity for neurolysis, visit the Florida Blue Medical |
|Coverage Guideline website at . Refer to Medical Coverage Guideline 02-61000-34, Neurolysis. |
|Section C |
Check ALL boxes that apply:
|Is the request for any of the following? |
|Check all that apply: |
| |Pulsed radiofrequency neurolysis, laser neurolysis, chemical neurolysis or cryoneurolysis of the facet joint. |
| |Radiofrequency neurolysis or cryoneurolysis of the thoracic facet joints, sacroiliac joints or for foot pain |
| |(e.g. Morton’s neuroma, plantar fasciitis, other neuritis of the foot). |
| |Additional diagnostic medial branch block following prior successful radiofrequency (RF) neurolysis at same level. |
| |Percutaneous non-pulsed radiofrequency neurolysis for cervical facet joints OR lumbar facet joints. |
| |Chemical neurolysis for foot pain associated with Morton’s neuroma. |
| |Chemical neurolysis for foot pain associated with plantar fasciitis or other neuritis of the foot. |
|What agent is used for neurolytic destruction? |
|Section D |
Check ALL boxes and complete all entries that apply to the member’s condition:
|Chemical neurolysis for foot pain related to Morton’s Neuroma |
|Yes No |
|Has a thorough history and physical been performed to accurately diagnosis the neuroma? |
| |
|Yes No |
|Have diagnostic tests ruled out other bony pathology? |
| |
|Yes No |
|Is there documentation of attempt and failure of physical/mechanical treatment? |
|Check all that apply: |
| |
|Padding |
| |
|Activity modification |
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|Strapping |
| |
|Change in shoe wear |
| |
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|Icing |
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|Physical therapy |
| |
| |
|Orthotic devices |
| |
|Other Describe: |
| |
| |
| |
|Yes No |
|Is there documentation of attempt and failure of pharmacological treatment? |
|Check all that apply: |
| |
|Medications (e.g., NSAIDS, unless contraindicated) |
| |
| |
|Nerve block |
| |
| |
|Anti-inflammatory injections (e.g., corticosteroids) |
| |
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|Local anesthetic injection |
| |
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|Other Describe: |
| |
| |
| |
|Yes No |
|Has imaging (fluoroscopic or ultrasound) been performed with chemical neurolysis procedure? |
| |
|Yes No |
|Has there been previous chemical neurolysis for Morton’s neuroma? |
|List dates of previous injections: |
| |
|Chemical neurolysis for foot pain related to Plantar Fasciitis and other neuritis of the foot |
|Yes No |
|Has a thorough history and physical has been performed to accurately diagnosis plantar fasciitis/neuritis? |
| |
|Yes No |
|Is there documentation of attempt and failure of physical/mechanical treatment? |
|Check all the apply: |
| |
|Padding |
| |
|Activity modification |
| |
| |
|Strapping |
| |
|Change in shoe wear |
| |
| |
|Icing |
| |
|Physical therapy |
| |
| |
|Orthotic devices |
| |
|Other Describe: |
| |
| |
| |
|Yes No |
|Is there documentation of attempt and failure of pharmacological treatment? |
|Check all that apply: |
| |
|Medications (e.g., NSAIDS, unless contraindicated) |
| |
| |
|Anti-inflammatory injections (e.g., corticosteroids) |
| |
| |
|Other Describe: |
| |
| |
| |
|Yes No |
|Has imaging (fluoroscopic or ultrasound) been performed with chemical neurolysis procedure? |
| |
|Yes No |
|Has there been previous chemical neurolysis for Plantar faciitis or other neuritis of the foot? |
|List dates of previous injections: |
| |
|Section E – Medicare Members |
Check all boxes and complete all entries that apply:
| Yes | No |Is the procedure for the destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerve branch? |
| Yes | No |Has the paravertebral facet joint been identified as the source of the member’s pain by undergoing a diagnostic paravertebral facet |
| | |joint (median branch) block? |
| Yes | No |Has the member failed conservative treatment which may include local heat, traction, NSAIDs and anesthetic? |
| Yes | No |Is the paravertebral facet joint destruction performed by qualified personnel? |
| Yes | No |Is the procedure performed with fluoroscopy guidance to confirm the proper position of needle electrode? |
| Yes | No |Has the member experienced temporary or prolonged abolition of the pain after a fact joint nerve block injection? |
| Yes | No |Do the medical records demonstrate that destruction was performed at the median branch of the spinal nerve innervating |
| | |the facet joint? |
| Yes | No |Is the procedure for the treatment of Morton’s Neuroma? |
|What failed conservative treatments (mechanical and pharmacological) were attempted? |
|How many sites were injected this session? |
|If multiple sites were injected, provide rationale for injection of more than one site per session: |
| |
Additional Comments:
| |
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|I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical |
|Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation |
|necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a |
|guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan |
|benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to |
|comply with such request may be a basis for the denial of a claim associated with such services. |
|Ordering Physician’s Signature: |Date: |
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